While working in the emergency department, the unit secretary says, “We just got a call that someone with a severe peanut allergy accidentally ate peanuts and is on the way.”. Which emergency equipment would the nurse gather to prepare for the client’s arrival? Select all that apply.
Intubation equipment and oxygen.
Epinephrine.
Blood administration equipment.
Foley catheter.
Correct Answer : A,B
Choice A rationale
Intubation equipment and oxygen are essential for managing airway obstruction and ensuring adequate oxygenation in a patient experiencing anaphylaxis due to a severe peanut allergy.
Choice B rationale
Epinephrine is the first-line treatment for anaphylaxis as it rapidly reverses the symptoms by constricting blood vessels, relaxing muscles in the airways, and reducing swelling.
Choice C rationale
Blood administration equipment is not typically required for managing anaphylaxis unless there is a concurrent condition that necessitates it.
Choice D rationale
A Foley catheter is not relevant to the immediate management of anaphylaxis.
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Correct Answer is C
Explanation
Choice A rationale
Auscultating for wheezing is important but not the first action. The priority is to administer epinephrine to counteract the severe allergic reaction.
Choice B rationale
Assessing the client’s level of consciousness is important but not the first action. Administering epinephrine takes precedence to stabilize the client’s condition.
Choice C rationale
Administering epinephrine is the first action. It is crucial to counteract the severe allergic reaction and prevent further complications.
Choice D rationale
Monitoring for hypotension is important but not the first action. Administering epinephrine is the priority to stabilize the client’s condition.
Correct Answer is C
Explanation
Choice A rationale
Informing the client that she will need to bring the tick for testing is not necessary. While having the tick can help identify the species and potential risk, it is not required for testing for Lyme disease. The diagnosis can be made based on clinical symptoms and blood tests.
Choice B rationale
Informing the client that the tick is needed to perform a test is incorrect. The presence of the tick is not required for testing for Lyme disease. Blood tests can detect antibodies to the bacteria that cause Lyme disease, even if the tick is not available.
Choice C rationale
Referring the client for a blood test immediately is the appropriate action. Early testing can help diagnose Lyme disease and initiate treatment promptly. Blood tests can detect antibodies to Borrelia burgdorferi, the bacteria that cause Lyme disease, and help confirm the diagnosis.
Choice D rationale
Asking the client about the size and color of the tick is not the most appropriate action. While this information can provide some context, it does not directly contribute to the diagnosis of Lyme disease. The priority is to refer the client for a blood test to confirm the presence of the infection.